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​Tips for success – ways to help programs meet accreditation requirements

The following tips are a compilation of ideas and suggestions provided by accredited programs, surveyors and the secretariat. The tips are shared with you in the hopes that they will help you integrate accreditation into your ongoing operations.

General administration:

  • Ensure that the program’s designated contact person for Conjoint Accreditation Services is aware of accreditation responsibilities (see The accreditation contact person: roles and ​responsibilities).
  • Encourage program personnel to participate as a surveyor or observer.
  • Solicit 1 or 2 program personnel with experience in the accreditation process to assist in preparing the program’s submission. Use the accreditation expertise of personnel from other accredited programs in your institution, e.g., to read the draft program submission, to conduct a “mock visit”.
  • Review the Program assessment reports of other programs within your institution. Benefit from the accreditation experience of these programs.
  • Consider a centralized folder (electronic or hard copy) for maintaining general institutional policies and procedures that are needed for the accreditation submission. Ensure that all accredited programs within your institution have access to any centralized folders.
  • Involve all personnel from the program in the accreditation process – accreditation should not rest on the shoulders of one person.

Cross-reference to the national competency profile

As a program team, develop a cross-reference document referring to the guidelines

  • Make it a useful tool for curriculum review by:
    • ensuring all competencies in the national profile are covered in the program;
    • identifying the course(s) where each competency is primarily taught;
    • allowing for easy updates and shifting of competencies within courses.
  • Review and revise the cross-reference document on a regular basis, e.g., in conjunction with an annual curriculum review meeting or its equivalent.
  • Consider using available curriculum design computer software that maintains an up-to-date centralized cross reference of competencies to courses.
  • Ensure that the cross-reference of competencies is verifiable within the program’s documentation of courses/learning activities. Make the cross-reference as specific as possible, e.g., refer to a learning objective within each course or include the competency number beside the specific learning objective. A reader must be able to confirm where each competency is covered.

Clinical sites

  • Ensure that signed agreements with clinical/practicum sites reflect the responsibilities of the institutions and that expectations are clearly defined.
  • Keep a master list of clinical placement sites with the effective date of current agreements and any termination dates.
  • Maintain a checklist of items that must be reviewed when considering new clinical placement sites. Ensure the list includes critical criteria for accreditation, e.g., adequate supervision, volume and variety of clinical experience available, exposure to safe working practices.
  • As part of the clinical placement selection process, consider asking new sites to complete the appropriate template.
  • Develop a standardized student orientation checklist for use by clinical personnel at all affiliated sites. Include items related to safety, roles and responsibilities.
  • Ensure that clinical personnel have the knowledge and tools to fulfill their responsibilities, e.g., use of assessment tools, frequency of assessments, how to give constructive feedback, etc.
  • Develop policies regarding storage and retention of student files to ensure that the privacy interests of the students and graduates are protected at all program sites.
  • Ensure that student attainment of competencies is documented and verifiable within the student record.
  • Notify Conjoint Accreditation Services when a new clinical site is added.


  • Use the templates to facilitate data presentation and tracking.
  • When appropriate, modify the templates to suit the program's needs.
  • Update templates regularly.

Program evaluation process

  • Collect evaluation data from all stakeholders, document the analysis of data and ensure program improvements are timely and recorded.
  • Create a planning guide for the program’s quality improvement process. Include methods and frequency for stakeholder evaluation of program components.
  • Compile the evaluation data for individual program components, involving program personnel in analyzing this evaluation data.
  • Schedule the review of the data to ensure the data is analyzed systematically and timely program improvements are made before the next cohort begins that component of the program. Document the review as well decisions and actions stemming from it.
  • Consider an executive summary to document the analysis and to:
    • highlight the program’s strengths and areas for improvements;
    • identify trends;
    • compare data on a year to year basis.
  • Use templates to document timely program improvements based on the analysis.
  • Add questions related to the critical criteria for accreditation to student evaluation surveys, e.g., questions on student receiving feedback in a timely manner and on the effectiveness of instructional delivery could be used as evidence that personnel are fulfilling their responsibilities.
  • Involve program personnel in all aspects of quality improvement processes.
  • Develop a system to monitor the program’s ongoing compliance with the requirements for accreditation.
  • Integrate accreditation into the program’s operational procedures – accreditation should not be an add-on but an integral component of the program’s continuous quality improvement process.